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A client with cardiomyopathy receiving diuretic therapy has a urine output of 200 mL in 8 hours. Which action by the nurse is correct?
- A. Assist the client to ambulate.
- B. Document a normal urine output.
- C. Notify the healthcare provider.
- D. Measure abdominal girth.
Correct Answer: C
Rationale: A urine output of 200 mL in 8 hours is considered low, especially for a client with cardiomyopathy who is receiving diuretic therapy. This could indicate inadequate cardiac output or worsening heart failure. It is crucial for the nurse to notify the healthcare provider promptly so that appropriate interventions can be initiated to address the underlying cause and prevent further complications. Waiting for improvement without taking action could lead to deterioration in the client's condition.
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A client diagnosed with a deep vein thrombosis (DVT) is receiving intravenous heparin. Which is the priority outcome for this client?
- A. The client will not disturb the intravenous infusion.
- B. The client will comply with dietary restrictions.
- C. The client will not experience bleeding.
- D. The client will keep the right leg elevated on two pillows.
Correct Answer: C
Rationale: The priority outcome for a client with deep vein thrombosis (DVT) receiving intravenous heparin is to prevent bleeding. Heparin is an anticoagulant medication used to prevent the formation of blood clots, but one of its potential side effects is bleeding due to its ability to prevent blood clotting. It is crucial to closely monitor the client for signs of bleeding while on heparin therapy, such as easy bruising, black or tarry stools, blood in the urine, or excessive bleeding from wounds. Preventing bleeding is essential to avoid complications associated with anticoagulant therapy.
A client who is taking beta-adrenergic blockers for angina is experiencing hypovolemic shock. Which does the nurse anticipate being the priority collaborative intervention for this client?
- A. Administering analgesics for control of pain
- B. Assessing the cause of bleeding
- C. Providing replacement of volume
- D. Establishing invasive cardiac monitoring
Correct Answer: C
Rationale: In a client experiencing hypovolemic shock, the priority collaborative intervention is to provide replacement of volume to improve tissue perfusion and restore organ function. Hypovolemic shock is characterized by a significant loss of intravascular volume, leading to inadequate tissue perfusion and oxygenation. Beta-adrenergic blockers can exacerbate hypovolemic shock by further decreasing cardiac output and blood pressure. Therefore, the immediate priority is to address the hypovolemia by providing volume replacement through fluid resuscitation to stabilize the patient before assessing the cause of bleeding or establishing invasive cardiac monitoring. Administering analgesics for pain control is important but not the priority in this situation.
After a stroke, sensory-perceptual changes increase the client's risk for what?
- A. Aspiration
- B. Injury
- C. Bleeding
- D. Infection
Correct Answer: B
Rationale: After a stroke, sensory-perceptual changes such as impaired proprioception, altered sensation, and decreased awareness of the affected side can increase the client's risk for injury. These changes can result in difficulties with balance, coordination, and spatial awareness, making the individual more prone to falls and accidents. It is important to implement safety measures and interventions to minimize the risk of injury in these clients, such as providing a structured environment, using assistive devices, and encouraging regular monitoring and assistance as needed.
A patient has developed a paralytic ileus following recent abdominal surgery. What is the most important nursing action when caring for this patient?
- A. Monitor bowel sounds every hour
- B. Maintain the patient on strict bed rest
- C. Ensure the nasogastric tube is functioning
- D. Ensure that the patient is given a clear liquid diet
Correct Answer: C
Rationale: Ensuring that the nasogastric tube is functioning is the most important nursing action when caring for a patient with a paralytic ileus. A paralytic ileus is a condition where there is a temporary paralysis of the intestine, leading to a lack of bowel motility. This can result in a buildup of gas and fluids in the intestines, causing abdominal distension, pain, and potential complications.
The nurse is caring for an adult client who was diagnosed with a congenital heart defect as a child, which was later repaired with surgery. Which common complication of a heart defect should the nurse monitor that the client may still be at risk for?
- A. Deep vein thrombosis
- B. Endocarditis
- C. Atherosclerosis
- D. Shock
Correct Answer: B
Rationale: Endocarditis is a common complication that individuals with repaired congenital heart defects may still be at risk for. Endocarditis is an infection of the inner lining of the heart chambers and valves. The altered structure of the heart tissue from the previous defect and surgery can create an increased risk for bacterial growth and infection. Patients with a history of congenital heart defects should be monitored for signs and symptoms of endocarditis, such as fever, fatigue, new heart murmurs, and evidence of systemic embolization. Prophylactic antibiotics before certain dental and surgical procedures may be recommended to prevent endocarditis in this population. Therefore, the nurse should be vigilant in monitoring for any symptoms suggestive of endocarditis in this client.